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Nutrition and Cardiovascular Disease: Evidence and Guidelin Nutrition and Cardiovascular Disease: Evidence and Guidelin

Nutrition and Cardiovascular Disease: Evidence and Guidelin - PowerPoint Presentation

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Nutrition and Cardiovascular Disease: Evidence and Guidelin - PPT Presentation

Nathan D Wong PhD Professor and Director Heart Disease Prevention Program Division of Cardiology University of California Irvine Dietary Effects on Lipids Seven Countries study showed significant correlation between saturated fat intake and blood cholesterol levels ID: 465905

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Slide1

Nutrition and Cardiovascular Disease: Evidence and Guidelines

Nathan D. Wong, PhD

Professor and Director

Heart Disease Prevention Program

Division of Cardiology, University of California, IrvineSlide2

Dietary Effects on Lipids

Seven Countries study showed significant correlation between saturated fat intake and blood cholesterol levels

Meta-analysis of randomized controlled trials shows lowering saturated fat and cholesterol to reduce total and LDL-C 10-15%

For every 1% increase in intake of saturated fat, blood cholesterol increases 2 mg/dl

Soluble fiber intake may provide additional LDL-C response over that of a low-fat dietSlide3

Dietary Effects on Thrombosis

Omega-3 fatty acids have antithrombogenic and antiarrhythmic effects, decreased platelet aggregation, and lower triglycerides

Eskimos’ cold water fish diet associated with prolonged bleeding times and lower rates of MI; similar findings in Japan, Netherlands, and England

Lyon Diet-Heart Study reported increased survival following Mediterranean diet with fish and high in linolenic acid (no lipid differences seen).Slide4

Associations between the percent of calories derived from specific foods and CHD mortality in the 20 Countries Study*

Butter 0.546

All dairy products 0.619

Eggs 0.592

Meat and poultry 0.561

Sugar and syrup 0.676

Grains, fruits, and starchy -0.633

and nonstarchy vegetables

Food Source Correlation Coefficient†

*1973 data, all subjects. From Stamler J: Population studies. In Levy R: Nutrition, Lipids, and CHD. New York, Raven, 1979. †All coefficients are significant at the P<0.05 level.Slide5

Men participating in the Ni-Hon-San study*

Age (years) 57 54 52

Weight (kg) 55 63 66

Serum cholesterol (mg/dL) 181 218 228

Dietary fat (% of calories) 15 33 38

Dietary protein (%) 14 17 16

Dietary carbohydrate (%) 63 46 44

Alcohol (%) 9 4 3

5-yr CHD mortality rate 1.3 2.2 3.7

(per 1,000)

Residence

Japan Hawaii California

*Data from Kato et al.

Am J Epidemiol

1973;97:372. CHD, coronary heart disease.Slide6

Epidemiologic studies*

Populations on diets high in total fat, saturated fat, cholesterol, and sugar have high age-adjusted CHD death rates as well as more obesity, hypercholesterolaemia, and diabetes

The converse is also true

What is the evidence for dietary intervention studies?

*Results from Seven Countries, 18 countries, 20 countries, 40 countries,

and Ni-Hon-San StudiesSlide7

Oslo Diet Heart Study

412 men with CHD, 5 year study

Treatment group randomized to low saturated fat (8.4% of calories), low cholesterol (264 mg/day), high polyunsaturated fat (15.5%) diet

Serum cholesterol reduced 14%

33% reduction in MI, 26% decrease in CHD mortality

Dietary counseling every 3 months

Leren et al.

Acta Med. Scand 1966; 466:1.Slide8

Los Angeles VA study

846 men in Veterans Home, 5-8 years

Groups randomized to diets in which 2/3 of fat given either as vegetable oil (corn, cottonseed, safflower, soybean) or animal fat

Saturated fat 11% vs. 18%, polyunsaturated fat 16% vs. 5% of calories

31% decrease in CVD endpoints

Dayton et al.

Circulation

1969; 40:1.Slide9

Lyon Diet Heart study

302 men and women with CHD

Treatment group randomized to low saturated fat, high canola oil margarine (5% alpha linolenic, 16% linoleic, and 48% oleic acid, also 5%

trans

)

46 month follow-up

65% lower CHD death rate in treatment group (6 vs. 19 death)

de Lorgeril et al. Circulation 1999; 99:779-785.Slide10

Stanford Coronary Risk

Intervention Project (SCRIP)

300 men and woman with CHD, baseline and 4 year follow-up angiograms

Randomized to <20% fat, <6% saturated fat, <75 mg cholesterol/day, and exercise (Rx group) vs usual care

LDL-C and TG decreased 22% and 20%, and HDL-C increased 20%

Rx group had 47% less progression than control group,

P

<0.02

Haskell et al.

Circulation 1994; 89:975-990. Quinn et al. JACC 1994; 24:900-908.Slide11

U.S. Diabetes Prevention Project

3234 subjects with BMI > 34 kg/m

2

Placebo, metformin, and lifestyle modification

Lifestyle modification goal > 7% weight loss with diet and exercise (

 150 min / week)

New onset diabetes: 11% placebo,

7% metformin, 4.8% lifestyle groupNEJM 2002Slide12

Finnish Diabetes Prevention Study

522 overweight subjects; Intervention group - met with dietician 4 x /yr and supervised exercise vs control group (pamphlet)

Goals: 1) 5 lb wt loss 2) 15gm of fiber/1000 cal 3) < 30% fat 4) < 10% saturated fat 5) 30 minutes of exercise /day

Intervention group met 4/5 goals 0% new diabetes, vs control group met 0 goals 32% new diabetes

NEJM 2001Slide13

Benefits of fish oil supplementation

In the Diet and Reinfarction Trial (DART) in 2033 men with CHD increased intake of fish or use of 2 fish oil caps/day reduced CHD mortality 29% over 2 years

In GISSI 11324 men and woman with CHD use of 1 gr. of n-3 PUFA decreased CVD events including mortality 15%

Lancet

1989; 2;757-761, and 1999; 345:447-455.Slide14

Nuts, Soy, Phytosterols, Garlic

Nurses’ Health Study: five 1oz servings of nuts per week associated with 40% lower risk of CHD events

Metaanalysis of 38 trials of soy protein showed 47g intake lowered total, LDL-C, and trigs 9%, 13%, and 11%

Phytosterol-supplemented foods (e.g., stanol ester margarine) lowers LDL-C avg. 10%

Meta-analysis of garlic studies showed 9% total cholesterol reduction (1/2-1 clove daily for 6 months).Slide15

Controversy regarding efficacy of Soy ProteinSlide16

Lifestyle Heart Trial

41 male and female CHD patients

Randomized to <10% fat diet, exercise and meditation (Rx group) vs. Step 1 diet

At one year 37% LDL-C reduction, 22% weight loss, and 1.8 % regression in Rx group vs 2.3% progression in control group (quantitative coronary angiography)

At 5 years 20% LDL-C reduction, 3.1% regression in Rx group vs 11.8% progression in control group (n=35)

Ornish et al.

Lancet

1990; 336:129-133, and

JAMA

1998; 280:2001-2007.Slide17

Dietary Approaches: Zone/Soy Zone

Premise is to reduce insulin levels and stabilize glucose control by limiting starchy carbohydrates, emphasize low-density carbohydrates.

Emphasis on protein (avg. 75g/day for women and 100 g/day for men) (one-third of plate) (soy protein products for Soy Zone) and carbohydrates (primarily from vegetables, fruits to a lesser extent). Allows limited monounsaturated fats.

Metaanalysis of clinical trial on soy protein (avg. 47g/day) showed reduction in total cholesterol of 9%, LDL-C 13%, and triglycerides 11% (NEJM 1995; 333: 276-82)Slide18

Dietary Approaches: Atkins

Intended to correct unbalanced metabolism by restriction of carbohydrates to reduce insulin production and conversion of excess carbohydrates into stored body fat

Induction diet limits carbohydrate intake to 20 gms/day (e.g., 3 cups of salad veg or 2 cups salad + 2/3 cup cooked vegs) to induce ketosis/ lypolysis. Maintenance diet 25-30 gms/day.

Pure proteins, fats, and protein/fat allowed (all meats, fish, foul, eggs, cheese, veg oils, butter)

Most carbohydrates are not allowed--fruits, bread, grains, starchy vegs, or dairy products.Slide19

Data on Atkins and Zone diets

Medline analysis 2001

No large scale (>50 subjects) long term (>6months) follow-up studies could be identified with weight loss, cardiovascular risk assessment or clinical outcome data

Slide20

Pritikin Lifestyle Program

3-week residential program with exercise and ad libitum low fat (<10% of calories) plant based diet

4566 men and woman

Mean LDL-C reduction 25% in men and 20% in woman

Significant reductions in TG and HDL-C

Significant 3.2% reduction in body weight

Limited long-term follow up

Barnard et al.

Arch Intern Med

1991;151:1389-1394.Slide21
Slide22

Very low fat

Ornish

(Reversal diet and Prevention diet)

Vegetarian with 10% calories from fat. No cooking oils, avocados, nuts, and seeds. High fiber. No caloric restriction.

Pritikin

Very low-fat (primarily vegetarian) diet based on whole grains, fruits, and vegetables

Intermediate

Sugar Busters

30% protein, 40% fat, 30% carbohydrates (low glycemic index)

Zone30% protein, 30% fat, 40% carbohydrates

Diet Evidence: Types of Treatment ProgramsSlide23

Very low carbohydrate

Atkins (Induction and Maintenance)

1

st

2 weeks (

<

20 grams of carbohydrates/day with no high glycemic foods).

Then can add 5 grams of carbohydrates/day each week to maximum of 90 grams of carbohydrates/day long term.

South Beach (3 Phases)

1st phase (2 weeks) significantly restricts carbohydrates2nd phase reintroduces low glycemic carbohydrates3rd

phase attempts to maintain weightCaloric restrictionWeight watchersAssigns foods a point value and restricts the number of points that can be consumed/day.

Diet Evidence:

Types of Treatment Programs (Continued

)Slide24

160 overweight and obese patients randomized to the Atkins, Zone, Weight Watchers, or

Ornish

diets for 1 year

Weight loss is similar among diet programs, but hard to sustain because of poor long-term compliance

Dansinger

, ML et al.

JAMA

2005;293:43-53

20/40*

26/40*

26/40*

21/40*

0

3

6

9

Atkins

Zone

Weight Watchers

Ornish

Wt loss (lbs)

*Ratio of individuals completing the study to those enrolled

Diet Evidence:

Primary PreventionSlide25

Lifestyle Heart Trial

41 male and female CHD patients

Randomized to <10% fat diet, exercise and meditation (Rx group) vs. Step 1 diet

At one year 37% LDL-C reduction, 22% weight loss, and 1.8 % regression in Rx group vs 2.3% progression in control group (quantitative coronary angiography)

At 5 years 20% LDL-C reduction, 3.1% regression in Rx group vs 11.8% progression in control group (n=35)

Ornish

et al.

Lancet

1990; 336:129-133, and JAMA 1998; 280:2001-2007.Slide26

Jenkins DJ et al.

JAMA

2003;290:502-10

0

10

20

30

-50

-40

-30

-20

-10

0

2

4

0

2

4

0

2

4

LDL-C

Change from Baseline (%)

LDL-C:HDL-C

CRP

Weeks

Weeks

Weeks

Low fat diet

Statin

Dietary portfolio*

*Enriched in plant sterols, soy protein, viscous fiber, and almonds

Diet Evidence:

Effect on Lipid Parameters and CRP

46

dyslipidemic

patients randomized to a low fat diet, a low fat diet and lovastatin (20 mg), or a dietary portfolio* for 4 weeks

A diversified diet improves lipid parameters and CRP levelsSlide27

Appel

LJ et al.

NEJM

1997;336:1117-24

Dietary Approaches to Stop Hypertension (DASH) Group

Diet Evidence:

Effect on Blood Pressure

A diversified diet improves blood pressure

459 hypertensive patients randomized to 1 of 3 diets for 8 weeks

Systolic blood pressure

(mm Hg)

Diastolic blood pressure

(mm Hg)Slide28

Diabetes Prevention Program (DPP)

Knowler WC et al.

NEJM

2002;346:393-403.

*Includes 7% weight loss and at least 150 minutes of physical activity per week

Placebo

Metformin

Lifestyle modification

Incidence of DM (%)

0

20

30

10

40

0

0

1

4

2

3

Years

Pre-diabetic Conditions:

Benefit of Lifestyle Modification

3,234 patients with elevated fasting and post-load glucose levels randomized to placebo, metformin (850 mg bid), or lifestyle modification* for 3 years

Lifestyle modification reduces the risk of developing DM Slide29

D

iabetes

P

revention

P

rogram:

Reduction in Diabetes IncidenceSlide30

Joshipura

KJ, et al.

2001

Ann Intern Med

134:1106-14

Nurses’ Health Study and Health Professional’s Follow-up Study

*Includes nonfatal MI and fatal coronary heart disease

CV=Cardiovascular, MI=Myocardial infarction

Diet Evidence:

Benefits of Fruits and Vegetables

126,399 persons followed for 8-14 years to assess the relationship between fruit and vegetable intake and adverse CV outcomes*

Increased

fruit and vegetable intake reduces CV riskSlide31

Pereira MA et al.

Arch

Int

Med

2004;164:370-76

RR=0.73, P<0.001

CV=Cardiovascular, CHD=Coronary heart disease

Diet Evidence:

Benefits of Whole Grains and Fiber

336,244 persons followed for 6-10 years to assess the relationship between dietary fiber intake and adverse CV outcomes

Increased dietary fiber intake reduces CV riskSlide32

Trichopoulou

A, et al.

NEJM

2003;348:2595-6

Variable

# of Deaths/ # of Participants

Fully Adjusted Hazard Ratio (95% CI)

Death from any cause

275/22,043

0.75 (0.64-0.87)

Death from CHD

54/22,043

0.67 (0.47-0.94)

Death from cancer

97/22,043

0.76 (0.59-0.98)

Diet Evidence:

Primary Prevention

22,043 adults evaluated for adherence to a Mediterranean diet, with points given for high consumption of vegetables, legumes, fruits, nuts, cereal, and fish and points subtracted for high consumption of meat, poultry, and dairy

High adherence to a Mediterranean diet is associated with a reduction in deathSlide33

Lyon Diet Heart Study

De

Lorgeril

M et al.

Circulation

1999;99:779-785

*High in polyunsaturated fat and fiber,

**High in saturated fat and low in fiber

Diet Evidence:

Secondary Prevention

605 patients following a MI randomized to a Mediterranean* or Western** diet for 4 years

A Mediterranean diet reduces cardiovascular eventsSlide34

Yokoyama M et al. Lancet. 2007;369:1090-8

Japan Eicosapentaenoic acid Lipid Intervention Study (JELIS)

*Composite of cardiac death, myocardial infarction, angina, PCI, or CABG

Years

w

-3 Fatty Acids Evidence:

Primary and Secondary Prevention

18,645 patients with hypercholesterolemia randomized to EPA (1800 mg) with a statin or a statin alone for 5 years

w

-3 fatty acids provide CV benefit, particularly in secondary prevention

CV=Cardiovascular, EPA=

Eicosapentaenoic acid Slide35

11,324 patients with a history of a MI randomized to

w

-3 polyunsaturated fatty acids [PUFA] (1 gram), vitamin E (300 mg), both or none for 3.5 years

GISSI Investigators.

Lancet

1999;354:447-455

w

-3 Fatty Acids Evidence:

Secondary Prevention

CV=Cardiovascular, MI=Myocardial infarction, NF=Non-fatal, PUFA=Polyunsaturated fatty acids

w

-3 fatty acids provide significant CV benefit after a MI

Gruppo Italiano per lo Studio della Sopravvivenza nell’Infarto miocardico (

GISSI-Prevenzione)Slide36

N-3 Fatty Acid Recommendation

American Dietetic Association 2007

For those without heart disease

Two 3.5 oz svgs/wk of fatty fish are assoc with 30-40% reduced risk of death from cardiac events.

Grade II FairSlide37

N-3 Fatty Acids

American Dietetic Association 2007

For those with heart disease

Approx 1g/d of DHA & EPA from fatty fish OR supplement decreases the risk of death from cardiac events.

Grade II FairSlide38

N-3 Fatty Acid Recommendation

American Dietetic Association 2007

Consume both marine & plant sources .

Fatty fish: two 3.5 oz serving/wk (salmon, herring, sardines)

or

1.5 g ALA/day eg 1 TBS canola, 1/2 TBS ground flax seeds.Slide39

2013 AHA/ACC Guideline on

Lifestyle Management to Reduce Cardiovascular Risk

Endorsed by the American Association of Cardiovascular and Pulmonary Rehabilitation, American Pharmacists Association, American Society for Nutrition, American Society for Preventive Cardiology, American Society of Hypertension, Association of Black Cardiologists, National Lipid Association, Preventive Cardiovascular Nurses Association, and WomenHeart: The National Coalition for Women with Heart Disease

© American College of Cardiology Foundation and American Heart Association, Inc.Slide40

Charge of Lifestyle Work Group

Lifestyle Recommendations

Evidence Review on Diet and Physical Activity (in the absence of weight loss) to be integrated with the recommendations of the Blood Cholesterol and High Blood Pressure PanelsSlide41

Lifestyle Workgroup Critical Questions

CQ1

Among

adults*,

what is the effect of dietary patterns and/or macronutrient composition on CVD risk factors, when compared to no treatment or to other types of interventions?

CQ2

Among adults, what is the effect of dietary intake of sodium and potassium on CVD risk factors and outcomes, when compared

with

no treatment or

with

other types of interventions?

CQ3

Among adults, what is the effect of physical activity on blood pressure and lipids when compared

with

no treatment, or

with

other types of interventions?

*Those ≥18 years of age and <80 years of age.Slide42

Lifestyle Topics: Dietary Patterns

Mediterranean Diet

BP and lipids

DASH and DASH variations

BP and lipids,

and in subpopulations

High- vs. Low-Glycemic Diets

BP and lipidsSlide43

Mediterranean-Style Dietary Pattern Evidence Yield

3 RCTs

conducted in free-living populations and

1 prospective

cohort study that met criteria for inclusion on strategies for CVD risk factor reduction

using

the Mediterranean-style dietary

pattern.Slide44

Mediterranean-Style Dietary Pattern Description

There is no uniform definition of the Mediterranean-style dietary pattern diet in the randomized trials and cohort studies examined.

The most common features in these studies were diets that were:

high

in fruits (particularly fresh) and vegetables (emphasizing root and green varieties)

high in

whole grains (cereals, breads, rice, or pasta)

fatty fish (rich in omega–3 fatty acids) low

in red meat (and emphasizing lean meats); substituted lower-fat or fat-free dairy products for higher-fat dairy foodsSlide45

Mediterranean-Style Dietary Pattern Description (cont.)

used oils (olive or canola), nuts (walnuts, almonds, or hazelnuts), or margarines blended with rapeseed or flaxseed oils in lieu of butter and other fats

The Mediterranean-style dietary patterns examined tended to be:

moderate in total fat (32%–35% of total calories)

relatively low in saturated fat (9%–10% of total calories)

high in fiber (27–37g/day)

high in PUFA

particularly omega–3sSlide46

Mediterranean Diet and BP

Counseling

to eat a Mediterranean-style dietary pattern compared to minimal advice to consume a low-fat dietary pattern, in free-living middle-aged or older adults (with type 2

diabetes mellitus or

at least

3 CVD

risk

factors): BP

by 6–7/2–3 mm HgIn an observational study of healthy younger adults, adherence to a Mediterranean-style dietary pattern was associated with:

BP 2–3/1–2 mm Hg Strength of Evidence: LowSlide47

Mediterranean Diet and Lipids

Counseling

to eat a Mediterranean-style dietary pattern compared

with

minimal or no dietary advice, in free-living

middle-aged

or older adults (with or without CVD or at high risk for CVD) resulted in

no consistent effect on plasma LDL-C

, HDL-C, and TG; in part because of substantial

differences and limitations in the studies. Strength of

Evidence: LowSlide48

DASH: Dietary Approaches to Stop Hypertension

2 RCTs (6 citations) evaluating the DASH pattern met eligibility criteria.

DASH dietary pattern description:

high

in vegetables, fruits, and low-fat dairy products

high

in whole grains, poultry, fish, and nuts

low in

sweets, sugar-sweetened beverages, and red meatslow in saturated fat, total fat, and cholesterol

high in potassium, magnesium, calciumrich in protein and fiberSlide49

DASH and BP

When

all food was supplied to adults with

BP

120–159/80–95

mm Hg

and both body weight and sodium intake were kept stable, the DASH dietary pattern,

compared with a typical American diet of the 1990s:

BP 5–6/3 mm Hg

Strength of Evidence: High Slide50

DASH and Lipids

When

food was supplied to adults with a total cholesterol level <260

mg/dL and LDL-C level <160 mg/dL

and body weight was kept stable, the DASH dietary pattern,

compared with

a typical American diet of the

1990s: LDL-C by 11 mg/dL

HDL-C by 4 mg/dL • no effect on TG

Strength of Evidence: HighSlide51

DASH Subpopulations and BP

When all food was supplied to adults with BP 120–159/80–95 mm Hg and body weight was kept stable, the DASH dietary pattern, compared with the typical American diet of the 1990s,

BP in:

women and men

African-American and non–African-American adults

older and younger adults

hypertensive and nonhypertensive adults

Strength of Evidence: HighSlide52

DASH Subpopulations, BP, and Lipids

In patients who would benefit from

 in BP and lipids, t

he DASH dietary pattern, when compared with the typical American diet of the 1990s,

BP and

LDL-C similarly in: women and menAfrican-Americans and non–African-American adults

older and younger adultshypertensive and nonhypertensive adults

Strength of Evidence: HighSlide53

DASH Subpopulations, Lipids

When

all food was supplied to adults with a total cholesterol level <260 mg/dL,

LDL-C level <160

mg/dL, and body weight was kept stable, the DASH dietary pattern, as compared to a typical American diet of the 1990s,

LDL-C and

 HDL-C similarly in subgroups: African-American

and non–African-American adults, and hypertensive and nonhypertensive adults.

Strength of Evidence: Low Slide54

DASH Variations (OMNIHeart Trial)

1 RCT met eligibility criteria for DASH eating pattern variations

In OmniHeart, 2 variations of the DASH dietary pattern were compared to DASH:

1 which replaced 10% of total daily energy from carbohydrates with protein

the other which replaced the same amount of carbohydrates with unsaturated fat Slide55

DASH Variation Evidence

BP

In

adults with BP of

120–159/80–95 mm Hg

, modifying the DASH dietary pattern by replacing

10%

of calories from carbohydrates with

the same amount of either protein or unsaturated fat (8% MUFA and 2% PUFA) lowered systolic BP by 1 mm Hg

compared to the DASH dietary pattern. Among adults with BP 140–159/90–95 mm Hg, these replacements lowered systolic BP by 3 mm Hg relative to DASH.

Strength of Evidence: Moderate

Slide56

DASH Variation Evidence (cont.)

Lipids

In

adults with average baseline

LDL-C

130 mg/dL,

HDL-C

50 mg/dL, and TG 100 mg/dL, modifying the DASH dietary pattern by replacing 10% of calories from carbohydrates

with 10% of calories from protein 

LDL-C by 3 mg/dL  HDL-C by 1 mg/dL

TG by 16 mg/dL compared to the DASH

dietary patternSlide57

DASH Variation Evidence (cont.)

Replacing 10% of calories from

carbohydrates

with 10% of calories from unsaturated fat (8% MUFA and 2% PUFA)

LDL-C similarly

 HDL-C by 1 mg/dL  TG by 10 mg/dL compared to the DASH dietary pattern

Strength of Evidence: Moderate Slide58

Glycemic Index/Load Dietary Approaches

3 RCTs evaluating glycemic index met eligibility criteria.

There is insufficient evidence to determine whether low-glycemic diets vs. high-glycemic diets affect lipids or BP for adults without diabetes mellitus.

The evidence for this relationship in adults with diabetes mellitus was not reviewed.Slide59

Lifestyle Topics: Dietary Fat and Cholesterol

Saturated Fat - Lipids

Replacement of SFA with carbohydrates, MUFA, or PUFA - Lipids

Replacement of carbohydrates with MUFA or PUFA - Lipids

Replacement of

trans

fatty acids with carbohydrates, MUFA, or PUFA, SFA - Lipids

Dietary Cholesterol - LipidsSlide60

Dietary Fat and Cholesterol

3 trials evaluating saturated,

trans

fat, and dietary cholesterol.

In addition a search was conducted for meta-analyses and systematic reviews from 1990 to 2009.

4 systematic reviews and meta-analyses met inclusion criteria. Slide61

Saturated Fat

Food

supplied to adults in a dietary pattern that achieved a macronutrient composition of

5%–6%

saturated fat,

26%–27%

total fat,

15%–18% protein, and 55%–59% carbohydrates compared

to the control diet (14%–15% saturated fat, 34%–38% total fat, 13%–15%

protein, and 48%–51% carbohydrates):  LDL-C 11–13 mg/dL in

2 studies

 LDL-C 11% in another study.

Strength

of

Evidence

:

HighNote: Saturated fat was not an isolated change.Slide62

Saturated Fat (cont.)

In

controlled feeding trials among adults, for every

1%

of energy from

SF)

that is replaced by

1% of energy from carbohydrates, MUFA, or

PUFA:LDL-C is lowered by an estimated 1.2, 1.3, and 1.8 mg/dL, respectivelyHDL-C is lowered by an estimated 0.4, 1.2, and 0.2 mg/dL,

respectively For every 1% of energy from SFA that is replaced by 1%

of energy from: Carbohydrates and MUFATG

are raised by an estimated 1.9 and 0.2 mg/dL, respectively.PUFA

TG

are lowered by an estimated 0.4 mg/dL

.

Strength of

Evidence:

Moderate Slide63

Effect of Substitution of 1% Energy of Saturated Fat

Carbohydrates, MUFA

MUFA

PUFA

LDL-C (mg/dL)

1.2

1.3

1.8

HDL-C (mg/dL)

0.4

1.2

0.2

TG (mg/dL)

1.9

0.2

0.4Slide64

Substitution of Fatty Acids for Carbohydrates

In

controlled feeding trials among adults, for every

1%

of energy from

carbohydrates that

is replaced by

1% of energy from: MUFALDL-C

is lowered by 0.3 mg/dL, HDL-C is raised by 0.3 mg/dL, and TG are lowered by 1.7 mg/dL PUFA

LDL-C is lowered by 0.7 mg/dL, HDL-C is raised by 0.2 mg/dL, and TG are lowered by 2.3 mg/dL Strength

of Evidence: ModerateSlide65

Trans

Fat

In

controlled feeding trials among adults, for every

1%

of energy

from

trans MUFA replaced with 1% of

energy from: MUFA or PUFA LDL-C

by 1.5 and 2.0 mg/dL, respectively. SFA, MUFA, or PUFA HDL-C by 0.5, 0.4 and

0.5 mg/dL, respectively. MUFA

or PUFA TG by 1.2 and

1.3 mg/dL.

Strength of

Evidence

: ModerateSlide66

Trans

Fat (cont.)

In

controlled feeding trials among adults, the replacement of

1% energy

as

trans

MUFA with carbohydrates decreased LDL-C cholesterol levels by 1.5 mg/dL, and had no effect on

HDL-C cholesterol and TG levels.

Strength of Evidence: ModerateSlide67

Dietary Cholesterol

There is insufficient evidence to determine whether lowering dietary cholesterol reduces LDL-C.Slide68

Lifestyle Topics: Sodium

BP:

Sodium Reduction - BP

Sodium Levels/ - BP and subpopulations

Sodium Reduction + DASH - BP

Sodium/ Other Minerals - BP

CVD Outcomes:

Sodium Reduction - CVD eventsSodium Intake - Stroke, CVD RiskSodium Intake - HFSlide69

Sodium and BP: Overall Results

In

adults aged 25–80 years with BP 120–159/80–95

mm Hg

, reducing sodium intake lowers BP.

Strength

of Evidence: HighSlide70

Different Levels of Sodium Intake

In

adults aged 25–75 years with BP 120–159/80–95

mm Hg, relative to approximately 3,300 mg/day

sodium

intake that achieved a mean 24-hour urinary sodium excretion of approximately 2,400

mg/day: 

BP by 2/1 mm Hg  Sodium intake that achieved a mean

24-hour urinary sodium excretion of approximately

1,500 mg/day 

BP by 7/3 mm Hg

Strength

of

Evidence

:

ModerateSlide71

Different Levels of Sodium Intake (cont.)

In

adults aged 30–80 with or without hypertension, counseling

to

sodium

intake by an average of 1,150 mg per

day:  BP

by 3–4/1–2 mm Hg Strength of

Evidence: ModerateSlide72

Sodium and BP in Subpopulations

In

adults with prehypertension or hypertension, reducing sodium intake lowers

BP in

women and men;

African-American

and

non–African-American adults; and older and younger adults.

Strength of Evidence: HighSlide73

Reducing

sodium intake lowers

BP in

adults with either prehypertension or hypertension when eating either the typical American diet or the DASH dietary pattern.

The

effect is greater in those with hypertension.

Strength of Evidence

: HighSodium and BP in

Subpopulations (cont.)Slide74

Sodium and Dietary Pattern Changes

In

adults aged 25–80 with

BP 120–159/80–95 mm Hg

, the combination of

sodium

intake + eating the DASH dietary pattern lowers BP more

than  sodium intake alone. Strength

of Evidence: ModerateThere is insufficient evidence from RCTs to determine whether

 sodium intake

+ changing dietary intake of any other single mineral (for example, increasing potassium, calcium, or magnesium) 

BP more

than

sodium

intake alone. Slide75

Sodium and CHD/CVD Outcomes

A

in sodium intake of ~1,000 mg/day

CVD events by ~30%.

Strength

of Evidence

: LowHigher dietary sodium intake is associated with a greater risk of fatal and nonfatal stroke and CVD.

Strength of Evidence: Low Slide76

There

is insufficient evidence to determine

the association between

sodium intake and the development of

CHF.

There

is insufficient evidence to assess

the effect of 

dietary sodium intake on CVD outcomes in patients with existing CHF.

Sodium and CHD/CVD Outcomes (cont.)Slide77

Lifestyle Topics: Potassium

Potassium intake – BP

Potassium intake – Stroke Risk

Potassium intake – CHD/ CHF/ CVD mortalitySlide78

Potassium and BP and CVD Outcomes

There

is insufficient evidence to determine

whether

dietary

potassium intake  BP.

In observational studies with appropriate adjustments (BP, sodium intake, etc.), higher dietary potassium intake is associated with

 stroke risk. Strength of Evidence

: LowSlide79

Potassium and BP and CVD

Outcomes (cont.)

There is insufficient evidence to determine whether there is an association between dietary potassium intake and CHD, CHF, and CVD mortality. Slide80

What’s New in Lifestyle?

Recommendations based on in-depth systematic reviews. P

revious reports used different methods and structure. More depth, less breadth.

More emphasis on dietary patterns

More data provided to support

saturated and

trans

fat restrictiondietary salt restrictionEvidence to support dietary cholesterol restriction in those who could benefit from 

LDL-C is inadequate.Slide81

Consume a dietary pattern that emphasizes intake of vegetables, fruits, and whole grains; includes low-fat dairy products, poultry, fish, legumes, nontropical vegetable oils and nuts; and limits intake of sweets, sugar-sweetened beverages, and red meats.

Adapt this dietary pattern to appropriate calorie requirements, personal and cultural food preferences, and nutrition therapy for other medical conditions (including diabetes).

Achieve this pattern by following plans such as the DASH dietary pattern, the U.S. Department

of

Agriculture (USDA) Food Pattern, or the AHA Diet.

LDL-C: Advise adults who would benefit from LDL-C lowering

*

to:

I

IIa

IIb

III

A

*Refer to 2013 Blood Cholesterol Guideline for guidance on who would benefit from LDL-C lowering.Slide82

Aim for a dietary pattern that achieves 5% to 6% of calories from saturated fat.

Reduce percent of calories from saturated fat.

Reduce percent of calories from

trans

fat.

LDL-C: Advise adults who would benefit from LDL-C lowering

*

to: (cont.)

I

IIa

IIb

III

A

I

IIa

IIb

III

A

*Refer to 2013 Blood Cholesterol Guideline for guidance on who would benefit from LDL-C lowering.

I

IIa

IIb

III

ASlide83

BP: Advise adults who would benefit from BP lowering to:

Consume a dietary pattern that emphasizes intake of vegetables, fruits, and whole grains; includes low-fat dairy products, poultry, fish, legumes, nontropical vegetable oils and nuts; and limits intake of sweets, sugar-sweetened

beverages,

and red meats.

Adapt this dietary pattern to appropriate calorie requirements, personal and cultural food preferences, and nutrition therapy for other medical conditions (including diabetes mellitus).

Achieve this pattern by following plans such as the DASH dietary pattern, the U.S. Department of Agriculture (USDA) Food Pattern, or the AHA Diet

.

I

IIa

IIb

III

ASlide84

Lower sodium intake.

Consume no more than 2,400 mg of

sodium/day;

Further reduction of sodium intake to 1,500

mg/day

can result in even greater reduction in BP; and

Even without achieving these goals, reducing sodium intake by at least 1,000

mg/day

lowers BP

.BP: Advise adults who would benefit from BP lowering to: (cont.)

I

IIa

IIb

III

A

I

IIa

IIb

III

BSlide85

Combine

the DASH dietary pattern with lower sodium intake.

BP: Advise adults who would benefit from BP lowering to: (cont.)

I

IIa

IIb

III

A